Towards Designing a Better Death: A Retrospective Analysis of Planned In-Hospital LVAD Deactivation Cases

Purpose Despite rapid growth of implanted durable mechanical circulatory support devices, best practices for device deactivation and end of life (EOL) care have yet to be elucidated. We wished to describe current practices in LVAD deactivation at EOL, identify unmet needs of dying patients, and develop best-practice protocols for LVAD deactivation. Methods Retrospective analysis of patients admitted at MedStar Washington Hospital Center who had planned LVAD deactivation prior to death between January 2017 and August 2019. EHR review extracted information regarding patient demographics, underlying cardiac history, LVAD implant course/complications, reasons for LVAD deactivation, clinical details of deactivation process including symptom management issues, unit of death, consultant participation, and family presence. Data was analyzed using descriptive statistics. Results Fifty-three patients (32% women, 67% African American, 64% non-ischemic cardiomyopathy) with median 267 days on durable MCS support (range 10-3326 days) were included in the analysis. Fourteen deaths occurred during LVAD index hospitalization; for the rest, patients sought hospital or emergency room care a median of twice in the year prior to death (range 0-16 occurrences). Final hospital length-of-stay was median 21 days (range 1-106). During planning for LVAD deactivation, PC was consulted in 33 cases (66%), hospital chaplaincy in 27 (51%), and ethics in 13 (25%). Forty deaths occurred in the hospitals cardiac ICUs, 12 in the advanced heart failure step-down unit, and 1 in the ED. Family members were present at deactivation in 39 cases (74%). Regarding EOL symptom management, at the time of deactivation most patients received opioids (94%) and benzodiazepines (66%). LVAD deactivation time was documented in only 18 cases (34%); in these cases, time from device deactivation to death was median 11 minutes (range 1 min to nearly 28 hours). Conclusion Our early outcomes identify existing practices that should be continued as well as opportunities to develop and implement best-practice protocols for LVAD deactivation, palliative symptom management, psychosocial/spiritual support, and ongoing education for involved providers.This retrospective case series review informs the creation and implementation of future collaborative LVAD deactivation policies and workflow guidelines.